Date of Filling Out Report: ___________
I.
A. Patient's Name: ____________________________________________
Birthdate: ____________________________________ Sex: ________
Address and Phone __________________________________________
B. Doctor at Time of Transfusion: _________________________________
Address ___________________________________________________
C. Hospital and Chart No. at Time of Transfusion: ____________________
D. Diagnosis at Time of Transfusion: ______________________________
E. Length of Hospital Stay: ______________________________________
F. Did Patient Receive Fibrinogen or Other Components? ___ Yes ___ No
II. A. Date of 1st Sign or Symptom of Hepatitis: ________________________
B. Description (Clinical Evidence of Hepatitis): _______________________
Laboratory Evidence of Hepatitis (including HBsAg test result): ________
__________________________________________________________
C. Additional History: other transfusion, contact with individual with hepatitis,
drug addiction (needle-sharing), current medications, and so forth. _____
___________________________________________________________
D. Hospital at Time of Hepatitis: ___________________________________
Doctor at Time of Hepatitis: ____________________________________
Duration of Hospitalization: ____________________________________
E. Outcome: __________________________________________________
1) Death: Date __________ Autopsy __________ Yes ________ No
Number: ________________________________________________
2) Recovery: a) Partial--Date:
_____________________________
b) Complete--Date: _____________________________
F. Donor numbers of implicated units: _____________________________
_________________________________
Name of Person Completing Form
Figure 3-6. Post-transfusion viral hepatitis history form.
MD0846
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